Foreword (1996) - Stanton's review of George Vaillant's "The Natural History of Alcoholism" revealed that the emperor was naked, and that the book was intellectually dishonest. Vaillant systematically created summaries that disputed his own data, while citing cases selectively to try to support what he perceived to be the safe positions to take. As a result of Stanton's review, Dr. Vaillant has for over a dozen years systematically attacked Stanton in speeches and workshops he gives around the nation, trying to square the circle by compulsively reinterpreting his (Vaillant's) data to show that alcoholics never resume controlled drinking.

New York Times Book Review, June 26, 1983, p. 10

Disease or Defense?

Review of the Natural History of Alcoholism, by George E. Vaillant

Stanton Peele

Review

Disputes about alcoholism reflect disputes in other areas of behavioral sciences but in an exaggerated way that leaves little middle ground between opposing positions. The dominant contemporary American view of alcoholism is that it is a disease. This position holds that alcoholism is innate and genetic, that its course is progressive and irreversible, that abstinence is the only solution to drinking problems and that Alcoholics Anonymous is the best  perhaps the only  means for an alcoholic to achieve sobriety. George E. Vaillant, a professor of psychiatry at Harvard Medical School, endorses the disease model in "The Natural History of Alcoholism," but he also reaches for the middle ground by taking into account the research-based, social-psychological perspective that opposes the disease theory.

The natural history of the title refers to the course of drinking habits over an individual's lifetime. The book is based on a 40-year study of about 600 men from two research populations  an upper middle class college group and an inner city group. In addition, Dr. Vaillant reports on the results of treatment over eight years of 100 men and women at a Cambridge, Mass. clinic of which he is the codirector. Dr. Vaillant used the natural history approach before with good success in "Adaptation to Life" (1977). Unfortunately, in contrast to that earlier book, his analysis here is dense, contradictory and weighed down by issues that he has not fully resolved in his own mind.

The results of this research do not provide ready support for the disease theory of alcoholism. Dr. Vaillant finds that more than half of the alcoholics in the inner city group evolved out of their drinking problems, generally without the assistance of treatment. He finds strong evidence in the inner city group for sociocultural causality in alcoholism. For example, Irish American subjects were seven times more likely to manifest alcohol dependence than subjects of Mediterranean descent. Dr. Vaillant also finds alcoholism running in families, which he uses as evidence of genetic causality, although he concedes that he cannot separate environmental and genetic factors in family similarities. Indeed, he specifically rebuts the idea that those with alcoholic relatives manifest drinking problems at an earlier age, as genetic theories have predicted, saying, "At the present time, a conservative view of the role of genetic factors in alcoholism seems appropriate." However, since Dr. Vaillant reports twice at other points that "genetic factors play a significant role in alcoholism," he creates an impression that is at odds with his own research.

Dr. Vaillant can be quoted to good effect on both sides of other issues in alcoholism, including the inflammatory question of controlled drinking. He says, "There appeared to be a point of no return beyond which efforts to return to social drinking became analogous to driving a car without a spare tire. Disaster was simply a matter of time." Yet he uncovers a substantial minority of alcohol abusers who returned to moderate drinking. (Dr. Vaillant actually reports two somewhat different figures for a return to moderate drinking among the inner city group and never gives a figure for the college population.) Alcohol abuse is not the same thing as alcoholism; Dr. Vaillant makes clear that only some alcohol abusers are alcoholics, but he also demonstrates that shadings between these categories are gradual and not well defined. Even so, one-fifth of the returned-to-moderate drinkers Dr. Vaillant finds in his study had been categorized as alcoholic according to psychiatric definitions.

The combination of contradiction and a good bit of redundancy makes this book hard to read even for those familiar with data tables and reference citations. "The Natural History of Alcoholism" contains less case description than "Adaptation to Life." But the cases that Dr. Vaillant does include work against the results of his data analysis. The cases belie the complexity of his research by emphasizing with monotonous regularity the need for an alcoholic to acknowledge he has an uncontrollable disease and to seek redemptive treatment for it. When Dr. Vaillant reports that some alcohol abusers and alcoholics do return to moderate drinking, he notes that his subjects did so for period averaging more than a decade. Dr. Vaillant argues that this duration means that these results must be taken seriously but then illustrates his point with the paradoxical example of a man who claimed to have moderated his drinking but instead collapsed and died.

The case reported most extensively is that of "James O'Neill," a model student and gifted individual who was a compulsive philanderer and totally irresponsible when he drank. Dr. Vaillant uses "O'Neill" to support his contention that alcoholism is not a response to personality problems but rather causes such problems independently. An alternate position  one that places the biology of alcohol's effects in a context of personal needs  is that alcoholism represents an attempt by the individual to palliate internal conflicts. This is the approach to behavior that Dr. Vaillant took in "Adaptation to Life," where he discussed the alcoholism of "Robert Hood" as an illustration of the "less adaptive aspects of acting out" to mask "inner pain" and "unhappiness."

Such contextual analysis is completely absent from "The Natural History of Alcoholism," although "Robert Hood" is a member of the same college population studied in both books. Dr. Vaillant's attitudes have changed since the previous study, because he has been immersed since then in the thinking that dominates alcoholism treatment. The purpose of this book, nonetheless, is to discover how well prevailing notions actually work. In this regard, Dr. Vaillant reports that 95 percent of the patients treated at his clinic, where A.A. attendance was compulsory, relapsed following treatment. After two and eight years, they showed no greater progress than comparable groups of untreated alcoholics. In acknowledging this, Dr. Vaillant confronts the dilemma of how to justify his faith in the efficacy of therapy. His resolution is to encourage the therapist not to interfere with the natural healing process.

In alcoholism research, where one side regularly parades a new study and the other then vilifies it, Dr. Vaillant's work can be cited approvingly by both. This is due in part to his admirable balance, fairness and honesty and in part to his willingness to accept contradiction and to defy his own research findings.